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Jigsaw Independent Hospital Requires improvement


Inspection carried out on 23 & 24 January 2018

During an inspection to make sure that the improvements required had been made

At the last inspection the service was rated as requires improvement, with ratings of good for effective, caring and responsive domains.

This inspection focused on the safe and well led domains, which were both rated as requires improvement previously.

Improvements had been made following the previous inspection. At the last inspection, there were issues with governance in terms of training levels, policies, ligature audits and out of date clinical stocks. At this inspection, we found most of these issues had been addressed with training monitored, policies updated, a new system for completing ligature audits in place and no medicines issues. Ligature risk assessments were improved although for one ward they did not capture all potential risks. Whilst there were records for regular supervision with staff and improved oversight, we were concerned about the use of a pre-filled template which staff signed.

At this inspection, we had concerns with oversight in terms of staffing, particularly that there had been occasions in the past six months were one registered nurse had been in charge of two wards and monitoring, in terms of assessing the quality of documentation, for example, moving and handling assessments.

We found issues with moving and handling assessments, falls risk assessments and care planning in relation to moving and handling and falls prevention.

Inspection carried out on 10 & 11 January 2017

During an inspection to make sure that the improvements required had been made

We rated Jigsaw Independent Hospital as requires improvement because:

We inspected Jigsaw Independent Hospital to see whether improvements had been made following a comprehensive inspection in March 2016. At that inspection, we had issued requirement notices for breaches of regulations relating to person centred care, good governance, staffing and duty of candour.

A warning notice had been served for a breach of regulation 12 of the Health and Social Care Act (2014) and an inspection visit in August 2016 confirmed that issues had been addressed and this warning notice was met.

At this current inspection, we found improvements and changes had been made throughout the hospital.

There had been a review of blanket restrictions throughout the hospital and many of the restrictions that had been in place had been altered. There was a collaborative multidisciplinary approach to delivering care. There had been a review of patient pathways throughout the service and evidence of discharge planning was apparent from talking to patients and reviewing records. The hospital now had a clear admission process.

In terms of good governance, we found records were well maintained and comprehensive. Physical health information was included in health passports. A new governance structure had been established and this ensured information was communicated up to board level and back down to ward level. A duty of candour policy had been developed and staff were aware of this. We found that although overall governance had improved, there were still areas which lacked sufficient oversight, for example, training levels, policies, ligature audits and out of date clinical stocks. There were also still issues with the Mental Health Act policies despite these being reviewed.

Inspection carried out on 23 August 2016

During an inspection to make sure that the improvements required had been made

This was a focused inspection relating to issues identified at a previous inspection following which we served a warning notice. We have not rated services at this inspection.

We issued a warning notice following a comprehensive inspection in March 2016 relating to regulation 12: safe care and treatment.

We found:

  • staff did not know about environmental risk assessments and what they needed to do to reduce risks.
  • there was no effective system in place to ensure that patients were only given medicine that was authorised
  • patients were not always getting their medicines as prescribed
  • patients who were prescribed high doses of antipsychotic medication, above the limits recommended in the British National Formulary (BNF), were not receiving increased monitoring to check for any adverse effects. There were no guidelines for high dose antipsychotic treatment and monitoring in the medication policy
  • medication was not stored appropriately, which meant that patients were at risk of being given medications which were not effective, and medicines were not being disposed of safely.

At this inspection, we assessed whether the service provider had put right issues identified in the warning notice. We found improvements in terms of safe care and treatment and that the provider had met the requirements of the warning notice.

We found:

  • staff knew about risks on their ward, how to reduce risks and all three wards had ligature risk assessments in place
  • forms for authorising treatment, certifications showing that a patient had consented to their treatment (T2) or that it had been properly authorised (T3) were completed and attached to medicine charts where required
  • staff checked medication stock levels to ensure the correct medicine was available for patients and records showed staff gave medicines to patients as prescribed. Staff ensured that patients who went on leave had their medicine with them. This was in the form of blister packs
  • the provider had reviewed the medicines policy, and it now included guidance on high dose antipsychotic monitoring and rapid tranquillisation monitoring. Staff completed a high dose antipsychotic monitoring form and patients’ care files had a sticker to indicate increased monitoring required
  • all medicines were in date and appropriately stored.

Inspection carried out on 21, 22 and 23 March 2016

During a routine inspection

We rated Jigsaw Independent Hospital as requires improvement because:

  • The hospital was not managing medicines safely. Patients were not always getting the medicines that were prescribed. The correct forms of authorisation or consent for detained patients did not always include all the medicines that were prescribed. There were no monitoring guidelines or policies for high dose antipsychotic treatment or for rapid tranquilisation.
  • Staff were not aware of the environmental risks on the wards and the actions needed to lessen them.
  • There were blanket restrictions in place, which meant that patients could not make hot drinks and snacks for themselves regardless of whether they had been assessed as safe to do so.
  • Training rates for five of the 16 mandatory training courses, including basic and immediate life support, were below the 75% target.
  • The information contained in the patients’ risk assessments was basic and did not always contain interventions.
  • Policies relating to the Mental Health Act had not been updated to reflect the current code of practice.
  • The appraisal rate for staff was low (39%) and only 60% of support workers and 71% of qualified staff had received supervision.
  • Patients had limited access to psychological support to aid their recovery. Patients did not know what they had to do to be discharged and care plans were not recovery focused.
  • Patients who were detained under the Mental Health Act were being prescribed medicines that were not included in the appropriate forms of consent.There were no admission criteria for the hospital so it was difficult to measure if the admission was appropriate
  • The governance system was not effective at identifying where care was falling below standards.


  • Risk assessments were completed on admission and reviewed regularly.
  • Staffing levels and skill mix were planned, and shortages were actioned promptly.
  • Patients had access to an independent mental health advocate.
  • Staff were caring and treated the patients with kindness and dignity.
  • Staff told us they were supported by the management team.
  • Complaints were managed well.
  • Patients detained under the Mental Health Act had their rights explained to them.
  • The service had good links with local commissioners.

Inspection carried out on 30 September and 1, 10 October 2013

During a routine inspection

We were accompanied by a Mental Health Act Commissioner (MHAC). The Mental Health Act Commissioner considers whether the hospital was working within the Mental Health Act and the Mental Health Act Code of Practice.

We spoke with seven people who were being cared for in this hospital about their care and treatment. The Mental Health Act Commissioner also spoke with people detained on the Mental Health Act on two units. Patients generally told us they felt well cared for and were happy. One patient stated: "I enjoy it here. We do all sorts". Detained patients told us that they had been given information about their rights. We heard mixed comments on the availability of the activities on the units. One person said: "Staff are alright - they talk to us at night, play table tennis; even the manager". Another person said: "There's not much to do in the way of activities". Some patients we spoke with commented on the bullying that occurs from other patients. Patients did state that they felt that staff did what they could to keep people safe and prevent incidents of bullying.

The provider was meeting all the essential standards we looked at on this inspection. We have made some suggestions in the report which the managers of the hospital may wish to consider.

Inspection carried out on 27 November 2012

During a routine inspection

We spoke with nine people who were being cared for in this hospital about their care and treatment. We also spoke with one relative of a person being cared for in this hospital. People we spoke with were generally felt positive about the care they received and felt safe most of the time. We were made aware that there had been instances of bullying by other patients on occassions. We discussed this with people who used services. We found that the service dealt with bullying and took active steps to deal with this issue.

We went with a Mental Health Act Commissioner. The Mental Health Act Commissioner considers whether the Mental Health Act and the Mental Health Act Code of Practice is being followed. They also proactively visit and interview people who are detained under the Mental Health Act. The Mental Health Act Commissioner interviewed a further six detained patients.

We found that the provider was meeting the standards we looked at during this inspection.

Inspection carried out on 16 December 2011

During an inspection in response to concerns

The people who use services we spoke with were positive about the care and support they received at the hospital. They told us they were getting the leave they were entitled to. People said that leave was only cancelled if they were not well enough to go out. They said that sometimes they had to wait to go out but staff always discussed any changes in arrangements with them. People who use services told us that staff looked after them well. They felt able to talk to staff and were confident that staff would help them. One person told us that they preferred being at Jigsaw than the previous hospital they had been at.

During an inspection to make sure that the improvements required had been made

This was a follow up review to check the provider's compliance with this outcome. We did not seek the views of the people who use services as part of the follow up review.

Inspection carried out on 31 January and 10 February 2011

During an inspection to make sure that the improvements required had been made

People told us that they were happy with the care they received at the hospital. They were complimentary about the staff. They felt that staff listened to them. They knew their rights and felt able to express concerns to staff.

Two people told us that they did not get all the Section 17 leave that they were entitled to. They said that they would prefer less frequent, longer periods of leave.

Reports under our old system of regulation (including those from before CQC was created)

Mental Health Act Commissioner reports

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.